Nokea
The nurse is providing medication for a client with osteomyelitis. What teaching
should the nurse indicate in the education?
- A. The most common adverse e effect for nonsteroidal anti-inflammatory drugs
(NSAIDS)are liver failure and tinnitus - B. The main side effect of acetaminophen is gastrointestinal GI bleeding
- C. You should not take more than 4000 mg of acetaminophen a day
- D. Nonsteroidal anti-inflammatory drugs (NSAIDS) are very safe and are known to have
no side effects
Correct Answer: A
Rationale:
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A client is in skeletal traction. With the nurse's assessment, it is noted that the
pairs appear red, swollen and there is purulent drainage. What action does the
nurse take first?
- A. Collect a culture of the purulent fluid
- B. Cleanse the skin around the pins
- C. Administer an antibiotic
- D. Instruct the client to complete exercise of the affected extremity
Correct Answer: A
Rationale:
A client is experiencing numbness and tingling distal to a new arm cast with no
increase in pain. The nurse assesses that the client's fingers are pale, cool and
swollen. What action does the nurse take next?
- A. Remove the cast to decrease pressure
- B. Raise the arm above the level of the heart
- C. Apply heat to the affected hand
- D. Encourage range of motion
Correct Answer: B
Rationale:
A client is in the emergency room in critical condition and hypotensive. Her
spouse is distraught. What is the priority nursing action?
- A. Maintain the client's blood pressure
- B. Call a chaplain
- C. Provide the spouse a chair
- D. Ask the client's spouse to explain what happened
Correct Answer: A
Rationale:
The nurse is performing a psychosocial assessment on a client with a severe
rheumatoid arthritis. What would be the most appropriate statement by the
nurse?
- A. "Tell me about what medication you are taking"?
- B. "What physical limitations are you experiencing?"?
- C. "How does this impact your role in your family?"?
- D. "What therapies are you using to reduce swelling?"?
Correct Answer: C
Rationale:
A client is immobile and requires mechanical ventilation with a tracheostomy.
She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse
observes bone and tendon at the base of the wound. How would the nurse
document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct Answer: D
Rationale: